Where is the most desirable place to do a medical residency?

This may seem like a trivial anecdote but it is one of my favourite examples of competitive forces at work. The University of Manitoba - Bannatyne campus is essentially the medical arm of the University of Manitoba. It's separate from the main campus and attached to the Health Sciences Centre which is the main hospital complex in Manitoba. Unfortunately because of contracts signed by the University of Manitoba all food services at the Bannatyne campus including coffee are provided by a certain soulless catering conglomerate. Now, I'm not entirely against greedy evil corporations like this one. They have a job to do which is to make money. But this company had a monopoly on all food services on campus which meant that you either ate their food and drank their coffee or shut up. They didn't have to compete and this made for poor service.

I remember in first and second year waiting in line at the campus Tim Horton's run by this multinational tool of a company. The line was never that long but they still took ages to get through. Once you got to the counter you were met by a coffee person (does barista apply at Tim Horton's?) with a glum look on their face who would brusquely take your order and shove a cup of hot coffee in your hands. The major kicker to all this was that, despite working in a building where you could literally take a picture of inside a persons brain, this Tim Horton's was a cash only affair. No debit or credit accepted. As a disorganized medical student who would regularly forget what day of the week it was, going to the bank for cash was way to advanced for me. So I would usually trudge by the Tim Horton's on the way to class disgruntled and coffee-less which was only slightly worse than standing in line for 20 minutes seething about the poor service.

Then, in second year, a hotel for families of patients opened up on the Health Sciences campus and inside that hotel was a Starbucks. This Starbucks, like any modern self-respecting business, had the ability to accept credit and debit purchases and so I began to spend all my money on Starbucks never to return to the Tim Horton's again except in desperation. But whenever I did go back I noticed, at least anecdotally, that the service was faster (if not nicer) and more importantly they had installed a debit machine. Moreover, the same company later set up their own Starbucks kiosk (with a debit machine) right across from the Tim Horton's in an attempt to capture some of the people who were buying coffee from the renegade hotel Starbucks.

This may seem like a small victory but its an important example of how competition works to make people better off. The hotel Starbucks forced the evil catering monopoly to change their business practices to make Tim Horton's more convenient for their customers. No longer did I or my disorganized cashless compatriots have to sit in a lecture without caffeine. We could get it whenever we wanted on demand.

This idea of voting with ones feet is an important part of competitive forces. People went to Starbucks instead of Tim Horton's and this forced them to change. But in a static sense competition also reveals desirability. Starbucks got more business than Tim Horton's because it provided a more desirable product.

This same idea can be used to (roughly) measure what university residency programs are the most desirable. Universities that are desirable should attract medical students to them and undesirable universities should drive medical students away. Medical students, like coffee customers, should vote with their feet. This seems simple in theory but its actually much harder to discern desirability in the residency match than in my coffee example. The problem with residency is that the number of spots that each program has are limited. At Starbucks you can line up out the door - theres no cap on demand. At a medical residency program though there are only so many spots and if you don't get one then, tough luck buddy, hit the bricks.

Because of this there are really two ways to get into a desirable residency. The first is to be a savant. On average desirable universities will have higher quality applicants and these applicants will get in ahead of their peers. The second way to get into a desirable program is luck. Village idiots get into desirable programs because all the stars align and they manage to fool their residency interviewers. This luck is helped when there are many of them. Like a swarm of mosquitoes, you can swat most of them down but, just on sheer numbers, one is going to get by you. 

So desirable universities should see high volumes of applications (the village idiot effect) from medical students at other schools and they should see high quality applicants (the savant effect) from other schools. Both will combine to result in a high number of medical students from other universities getting into desirable universities.

Besides this though a truly desirable program should be widely desired. If Manitoba is a desirable place to go for residency (this is obviously an example) there should be a high percentage of med students from UBC and McGill and Toronto and Calgary etc. who all get into the University of Manitoba. It shouldn't just be that all of the outside students are from Saskatchewan. Less desirable schools may see high numbers of med students from nearby schools come to them because of geography or whatever but they won't see large numbers or medical students from distant schools. Their popularity won't be wide spread. 

So the metric I use to gauge desirability is the average percentage of each medical school class that goes to do a residency at a particular university. This does not include those medical students that stay at their home school. So this metric for desirability at university x is then

where r is the number of incoming residents who go to university x for residency from university i, m is the number of medical students in each graduating class, and j is the number of medical schools. This is just a fancy way of saying the average percent of all other medical classes that go to university x is the proxy that I use for desirability.

For this, I took data for this from the Canadian Residency matching service website (CARMS) from their published match reports.  Although CARMS publishes a report every year most of their data is not in user friendly form and I was lazy. I only examine two years of data - 2004 and 2014. 

Below is the ranking for 2014. This shows that on average, medical schools (excluding the University of Toronto) saw about 9% of their class go to the University of Toronto for residency. This places UofT as top school by this metric. Conversely, just under 1% of any given medical school class (excluding Saskatchewan) went to the University of Saskatchewan for residency.

In everything thats preceded this, I deliberately avoided defining what a desirable residency program is to avoid speculation about what desirable attributes are. There are a lot of individual decisions that medical students make when they choose a residency program. But you can pick out at least partly why some of these places are low on the rankings and some are high on the rankings. The bottom four schools including my own soon-to-be alma mater are in "undesirable" locations.  The top five on the other hand are in "nice" cities or near nice cities (I'm looking at you McMaster). These top five universities also have anecdotal reputations for being good teaching programs which probably drives desirability as well. On thing I am surprised about is that Calgary isn't higher. It has a reputation for being a difficult place to get a residency position but this may just be a sign that this metric isn't that good of an indicator for desirability.

Universities in Quebec are also fairly far down the rankings. I suspect this is for two major reasons. First, you not only have to speak French in these residency programs but medical French. Medical school is basically a four year language program in latin sounding medical terminology so to do this all over again in a different language is probably not enticing for english speaking medical students. Second, pay for residents in Quebec is the lowest in the country. By quite a bit.

Next interesting question - how have these rankings changed in the last 10 years? I had to exclude the Quebec universities (except McGill) and NOSM because there was no data on the Quebec universities and because NOSM didn't exist in 2004. But for the remaining universities below is a linkplot of the rankings in 2004 and 2014 by school. 

Both Toronto and Saskatchewan retain their places as top and bottom school respectively. There are however a couple of major moves that occurred over the decade. McGill's ranking plummeted five spots largely, I suspect, because of the pay issue that I mentioned above. Quebec just didn't keep up with the wage bumps that other provinces gave to their residents. Western's ranking dropped as well, and I really don't have any explanation for that.

Calgary jumped a couple spots probably due to its growth as an oil town and all around hip place to be in the last ten years. Alberta has also thrown a lot of money at their medical system which probably partially drove this rise in desirability. Calgary also has a reputation (perhaps undeserved) of being a school with a good "work-life balance". Depending on interpretation this either means its a program thats rife with lay-about residents or its a program where they don't abuse their residents.

Queen's and McMaster also both jumped three spots and I also really couldn't say why. Maybe they bled off some of the medical student demand that had been going to Western, but I'm not sure. Both just finished building new medical school buildings so that might be part of it as well. Feel free to speculate wildly.

Now, before you send me an angry email about how your program is the best and I'm wrong and this ranking is completely incorrect blah blah blah let me tell you what this data does not say. As with most statistics it does not say anything about desirability of a residency program for an individual. My (failed) attempt to be agnostic about what desirable means was because desirability is really something that individual medical students determine. This is an average desirability for the average medical student. I know many people who have stayed in Manitoba because that fit best for them even though I rank it here as an "undesirable" place. Kids, condos, and familiarity make a place desirable for many people. Reflecting this, a decent chunk of people in medical school stay at their university for their residency (except Queen's which only retained a shocking 17% of its class last year). Similarly, the match isn't just about where you go but to what specialty program you go to. Someone who wants to do plastic surgery no matter what doesn't really care if they do it at the UofT or Memorial.

Moreover I suspect the actual training that one receives at all of these universities is essentially the same. There are certainly places that specialize in certain things but for the vast majority of medical students who are going into family medicine they receive about the same training at UofT or UofS. I would say this ranking of desirability is much more about location (Toronto, Vancouver, Calgary etc.) than reflective of the quality of university program.

The metric I use here is also of questionable quality. It's definitely subject to problems because it doesn't control for size of the accepting program. A larger program can absorb more students from other smaller schools and this would bump up its desirability metric. This problem may be reflected in why Toronto is first in both 2004 and 2014. It likely had the largest residency class in both years. But I'm too lazy to investigate this further. Now, if CARMs had released ranking data on location of program (i.e. number of people who ranked UofT first) then this whole logical exercise would be useless. But they don't and so we have to deal with a proxy of what we're actually trying to measure. As in the ranking of Calgary it gives some questionable results so I'm not sure how much to trust it.

This also says nothing about how good of a medical student someone is based upon the program they got into. While there will likely be a higher number of "savants" at desirable programs that doesn't mean a whole lot. I didn't define the term savant on purpose because residency programs are often quirky about what makes a medical student competitive. Besides this, there is a pretty decent chunk of luck built into getting a residency. Very smart people get into the University of Saskatchewan and village idiots like myself get into the University of Toronto. It's better to be lucky than good.